A 66-year-old man with limited prior medical contact presented with a 6-week history of progressive shortness of breath. He was diagnosed with a completed inferior myocardial infarction with inferior Q waves, 1-mm residual inferior ST elevation, and a troponin I > 25 000 ng/L. Diagnostic coronary angiography demonstrated a right-dominant system with 100% mid-right coronary artery occlusion without collaterals and 90% proximal left anterior descending artery occlusion with slow flow distally. Contrast-enhanced transthoracic echocardiogram revealed a large intramyocardial dissecting haematoma with a thin intact layer of endocardium delaminated from the remainder of the myocardial wall (Panel A). The distal anteroseptal and anteroapical myocardial wall segments were separated from the functional left ventricular (LV) cavity by the delaminated layer and appeared to have ruptured (Panels B–D). The LV systolic function was severely reduced (<20%). Cardiac magnetic resonance imaging (MRI) showed a large contained intramural haematoma originating in the mid-inferior septal segment, which dissected towards the apex and base measuring 3.7 cm × 4.5 cm × 4.7 cm at the apex. The myocardial discontinuity was less well visualized by MRI than echocardiography. After consultation with cardiac surgery, he was managed conservatively in the acute phase with medical therapy as he was clinically stable and did not require inotropic support.

中文翻译：

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如何通过晶须逃脱灾难性的心肌破裂

一名 66 岁男性，既往医疗接触有限，因进行性呼吸急促 6 周就诊。他被诊断为完全性下壁心肌梗死，伴下壁 Q 波、1 mm 残余下壁 ST 抬高和肌钙蛋白 I > 25 000 ng/L。诊断性冠状动脉造影显示右显性系统，100% 中右冠状动脉闭塞无侧支，90% 近端左前降支闭塞，远端缓慢血流。增强的经胸超声心动图显示一个大的心肌内夹层血肿，有薄的完整的心内膜层从心肌壁的其余部分剥离（图A）。远端前间隔和前心尖心肌壁段通过分层层与功能性左心室 (LV) 腔分开，并且似乎已经破裂（图 B-D）。LV 收缩功能严重降低 (<20%)。心脏磁共振成像 (MRI) 显示一个大的壁内血肿起源于中下间隔段，向顶点和基底解剖，在顶点处测量为 3.7 cm × 4.5 cm × 4.7 cm。与超声心动图相比，MRI 对心肌不连续性的可视化效果较差。在与心脏外科会诊后，由于临床稳定且不需要正性肌力药物支持，他在急性期接受了保守治疗，并接受了药物治疗。